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Home My WebLink About326303 06/12/18 �y_CAq CITY OF CARMEL, INDIANA VENDOR: 355486 ONE CIVIC SQUARE INDIANA ALCOHOL&TOBACCO COMNPHECK AMOUNT: $*****1,000.00* :9 ;�� CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 326303 ''��rpN�°. INDIANAPOLIS IN 46204 CHECK DATE: 06/12/18 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1207 4355300 1,000.00 ORGANIZATION & MEMBER VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995) Vendor# 355486 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER INDIANA ALCOHOL&TOBACCO COMM IN SUM OF$ CITY OF CARMEL 302 W WASHINGTON ST ROOM E114 An invoice or bill to be properly itemized must show:kind of service,where performed,dates service rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. INDIANAPOLIS, IN 46204 Payee $1,000.00 Purchase Order# ON ACCOUNT OF APPROPRIATION FOR Brookshire Golf Course Terms Date Due PO# ACCT# DATE INVOICE# DESCRIPTION DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT 2019 BGC Permit 43-553.00 $1,000.00 1 hereby certify that the attached invoice(s),or 6/11/18 2019 BGC Permit Permit Renewal $1,000.00 Renewal Renewal 1207 101 bill(s)is(are)true and correct and that the 1207 101 t materials or services itemized thereon for which charge is made were ordered and received except Monday, June 11,2018 d, I V1 I hereby certify that the attached invoice(s),or bill(s),is(are)true and correct and I have audited same in accordance with IC 5-11-10-1.6 ,20— Cost 20Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer - :FOR;OFFIGE,USEONCY, tip APPLICATION FOR RENEWAL OF Examined by/date(min/dd/yy) ��- • � ALCOHOLIC BEVERAGE PERMIT Hearing date(mm%dd/yy) State Form 47(R17/8-16) ` : Approved by State Board of Accounts,2016 Issue date_(mm/dd/yy); INSTRUCTIONS: 1.Type or print legibly. New eiipiratlori date(mm/dd/yy) 2.Include payment. ,Relfease date(mm7dd/yy) 3.Application must be received by our office ninety(90)days before permit expires. 4.Do not complete shaded areas. 5.Please attach completed Property Tax Clearance—Form 1. 6.Please attach a copy of the Retail Merchant Certificate from Indiana Department of Revenue. pease fee :STEP1".GENERAL"`INFORMATION,'"; Name of applicant as printed on existing permit Permit number Permit type City of Carmel RR2903542 210-1 Cateiing Name of business(d/b/a) Permit expiration date(mm/dd/yy) Brookshire Golf Club 7-13-18 Business address(number and street,city,state,ZIP code) Business telephone area/number .Name:of processor.; 12120 Brookshire Pkwy (317)846-7431 `a Home telephone area/number Date of renewal(mm/dd/yy) Carmel, IN 46033 ( ) Mailing address(number and street,city,state,ZIP code) Same as above Status RrActive :'Excisedistrict. ❑Non-operational/escrow (Attach escrow letter.) Local board 1)Have there been any changes in the existing operation,floor plans,or seating accommodations since you last applied for or renewed this permit?(If Yes,attach affidavit of changes and copies of amended floor plan on 8.5"x 11"paper,if applicable.) El Yes Q No 2) Do you consent for the duration of the permit to inspection and search by an enforcement officer,without a warrant or other process, of your licensed premises and vehicles to determine compliance with the provision of Indiana Code 7.1? ®Yes ❑No 3) Do any individuals,corporations,limited liability companies,limited liability partnerships,partnerships or stock owners,members,or partners of such entities have any interest,either directly or indirectly,in any other permits of any kind issued under Indiana Code 7.1 ❑Yes 0 No connected with,but not limited to,the production,distribution,transportation,or sale of alcoholic beverages? (If yes,attach a list of all permits.) 4)Since your last renewal,have you or anyone with an interest in this permit been convicted of a misdemeanor or felony? (If yes,please attach letter with dates,court conviction,and sentence of conviction.) ❑Yes No 5)Do you have the right to possess(rent,mortgage,or own)the permit premises for the term of the permit? Q Yes ❑No 6) Have applicant's sales taxes,withholding taxes,and property tax obligation for the past year and those due at this time been paid in full? 0 Yes ❑No 7)Do you sell tobacco products? If El Yes 0 No yes,list Tobacco Sales Certificate Number. 8) Do you have a Type II Gaming endorsement? Yes No If yes,list Gaming Endorsement Number. ❑ � STEF 2:,BlL51NESS•`OWNERSHIP Check one: ❑Corporation ❑Limited liability company ❑Partnership ❑Limited partnership Club ❑Limited liability partnership ❑Sole ownership 0 Government entity CORPORATIONS ONLY Note:If the ownership has changed(by death,transfer,or sale of stock or interest,etc.)since you last applied for renewal,the processor should be notified at once before completing this section. Provide the information for the individuals associated with your permit as follows: Total shares authorized CLUB—Highest ranking officer and the financial secretary or treasurer CORPORATION—President,secretary,and all stockholders (List total shares authorized/issued and individual shares held and percent of shares issued.) LIMITED LIABLITY COMPANY—All members and percent of interest held Total shares issued LIMITED PARTNERSHIP/PARTNERSHIP/LIMITED LIABILITY PARTNERSHIP—All partners and percent of interest held SOLE OWNERSHIP—Owner GOVERNMENT ENTITY—Government official(s)responsible for permit TITLE(Enclose additional NAME AND HOME ADDRESS "SOCIAL SECURITY NUMBER& SHARES OR INTEREST %'• sheet if necessary.) (number and street,city,sate,and ZIP code) DATE OF BIRTH(mm/dd/yy) HELD IF APPLICABLE Mr' Rober Higgins SSN 309-98-7324 20971 Shoreline Ct.#210 Noblesville,IN 46062 DOB 07-29-71 SSN DOB SSN DOB "Social Security Numbers are required by federal child support law. This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it. "Percent must be included,except for a club,sole owner,or government entity. A shareholder with more than 50%ownership may individually sign transfer paperwork. sttP'-1-,,-ANNUAL'SALES"/P, '(AHfio't,irOs-hri'sii j, t4i b ect,46, rifli n Retail ordeal e r permit(Skip Step 3 if permit was In escrow for the prior permit year.) 1) Do you hold a beer,wine,and liquor retail permit issued in an unincorporated area or a type 209 permit? El Yes ONo 2) Do you hold a beer,wine,and liquor retail permit with limited bar/family room separation? El Yes RI No 3) Do you operate a convenience store or food mart as defined by Indiana Code 7.1-1-3-18.5(a)(2)? El Yes ONo 4) Do you hold a retail or dealer permit through a partnership,corporation,limited partnership,or limited liability El Yes 2;,jo company that does not meet the residency requirements of Indiana Code 7.1-3-21-4,7.1-3-21-5,7.1-3-21-5.2,or 7.1-3-21-5.4? If you answered no to questions 1-4,skip to Section 4. Date of beginning report(mmlddlyy) Date of ending report(mmlddlyy) A. Gross food sales (For retail permits,exclude a//carryout and catering sales.) _7SS alcoholic beverage sales C. Total Gross Sales(Column A+B) (For convenience stores,exclude gasoline and automotive oil products.) Manufacturing permit(winery,farm winery,artisan distillery,distillery,and brewery) Date of beginning report(rnmlddlyy) Date of ending report(mmlddlyy) Gallons(farm winery or distillery)or barrels(brewery)manufactured StE 4..jpp -INFOR EIRATION Is there a contract of any kind to sell the permit/business at this time? El Yes V1 No Haveall of youremployees orservers obtained employee permits and completed employee training if required byIndiana Code JZ Yes E]No 7.1? As the owner do you manage the premises? If no,does the manager of the premises have a valid manager's questionnaire on file with the ATC? E]Yes 2 No] Eyes ONo_ Are you a grocery store or pharmacy? 0 Yes(If yes,move on to Step 5.) 5Z No(if no,then you MUST complete the rest of this section.) The Alcohol and Tobacco Commission requires managers as follows: •They must have been and Indiana resident for five(5)years or work in a restaurant with a minimum of$100,000 annual food sales; •They must be a United States citizen or resident alien; •They must be of sound mind,twenty-one(21)years of age and.of good moral character; •They cannot be a law enforcement officer;and •They cannot have a conviction within the last ten(10)years of • an A,B or C felony,or its equivalent in another state, • a level 1,2,3,4,or 5 felony,or its equivalent in another state,or a federal crime with a sentence of at least one(1)year. Do you understand the requirements and attest that the managers listed below meet these qualifications? (initial) The ATC requires the following: • At least one(1)owner or manager for each permit premises; • The manager must have an employee permit unless he or she is a sole proprietor,partner,or stockholder; • The manager is someone who has day-to-day authority over: 1. Employees that hold employee permits(i.e.bartenders,servers); 2. The receipt,inventory,stocking and marketing of alcoholic beverages;and 3. The premises,in the event of an emergency. LISTTHE MANAGERS FOR THIS PREMISES(ENCLOSE AN ADDITIONAL SHEET IF NECESSARY.) NAME EMPLOYEE PERMIT NUMBER or OWNERSHIP TYPE EMERGENCY TELPHONE NUMBER Robert Higgins BR1606858 317-501-2146 'qF' F�5�1 'FF1 T' "A I certify that there have been no changes regarding my previous application except those noted herein. I certify that this application was completed by myself or by the preparer identified herein. I certify that if this application was completed by a preparer,I have read the completed application.I certify that the ownership of my premises is true and that I will provide a copy of any applicable lease or purchase by contract upon request of the ATC. I certify that I have met any applicable food and beverage sales requirements. I certify that all information provided herein and on any attached schedules or documents are true and correct. I UNDERSTAND THAT IT IS A FELONY UNDER LAW TO MISREPRESENT OR FALSIFY ANY PORTION OF THIS APPLICATION OR ATTACHED DOCUMENTS. Printed name of applicant Signat7 0 pplicant Date(mmlddlyy) Robert Higgins 6-11-18 77-7777--777'7 STEP.6AFFIDAVIT I AREI;(�f_AP-P L I certify that I have examined this application and the accompanying forms,schedules,and statements,and to the best of my knowledge and belief,they tr ,correct,and complete. I certify that the applicant reviewed the completed form prior to signing. s" a e of prep er Telephone number Date(mm/dd/yy) 7r -11-18 '4 ( 317 846 - 7422 6 STEP Please remit business check,certified check,or money order—application Mail to: will not be processed without payment. (See attached fee schedule.) Indiana Alcohol&Tobacco Commission 302 West Washington Street,Room E114 Indianapolis,Indiana 46204 5T.�.4 PROPERTY TAX CLEARANCE SCHEDULE-FORM NO. 1 ATC permit number (For a ❑ Person ❑ Business ❑ Corporation) RR2903542 State Form 1462(R6/7-10) Expiration date(month,day,year) Approved by State Board of Accounts,2011 7-13-18 INDIANA ALCOHOL AND TOBACCO COMMISSION talo Name of individual'or company TYPE City of Carmel (Check all that apply) If transfer,give former name of business ❑New Mailing Address(street and number of rural route) El Renewal One Civic Square ❑Transfer(Check all that apply) City State ZIP Code ❑Ownership Carmel IN 46032 ❑Location Doing business as(DBA) ❑Stock Brookshire Golf Club Permit location(street address) STATUS 12120 Brookshire Pkwy ❑Permit escrow City State ZIP Code ❑DBA change Carmel IN 46033 I,Treasurer of Hamilton County,hereby certify that the person or company named above has paid all property taxes in 20 (for 20 assessment)and property taxes for all prior years,or is exempt from property tax by reason of Signature of County Treasurer Date(month,day,year) �8 STA PROPERTY TAX CLEARANCE SCHEDULE-FORM NO. 1 ATC permit number (For a ❑ Person ❑ Business ❑ Corporation) RR2903542 l00j's State Form 1462(R6/7-10) Expiration date(month,day,year) Approved by State Board of Accounts,2011 7-13-18 � 1e` INDIANA ALCOHOL AND TOBACCO COMMISSION Name of Individual or company TYPE City of Carmel (Check all that apply) If transfer,give former name of business ❑New Mailing Address(street and number ofrural route) EI Renewal One Civic Square ❑Transfer(Check all that apply) City State ZIP Code ❑Ownership Carmel IN 46032 ❑Location Doing business as(DBA) ❑Stock Brookshire Golf Club Permit location(street address) STATUS 12120 Brookshire Pkwy ❑Permit escrow City State ZIP Code ❑DBA change Carmel IN 46033 I,Treasurer of Hamilton County,hereby certify that the person or company named above has paid all property taxes in 20 (for 20 assessment)and property taxes for all prior years,or is exempt from property tax by reason of Signature of County Treasurer Date(month,day,year)